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Presenter: Dr. Shashi K. SinghModerater: Dr. Kumar Shrestha, Dr. Piyush,Dr. Jainendra Chaudhary, Dr. Indra K. Jha
• Burns is defined as a wound caused byexogenous agent leading to coagulativenecrosis of the tissue.
Causes• Thermal BurnsDry heatContact burnFlame burnMoist heat- Scald burnSmoke and inhalational injury• Chemical Burns- acids & alkali• Electrical burns- High & low voltage• Cold Burns- frostbite• Radiation
Thermal Burns• Heat changes the molecular structure of tissueCausing Denaturion of proteins• Extent of burn damage depends on–Temperature of agent–Amount of heat–Duration of contact
• The effects of the burns are influenced bythe:1.Intensity of the energy2.duration of exposure3.type of tissue injured
Pathophysiology of Burns• Fluid Shift– Period of inflammatory response– Vessels adjacent to burn injury dilate → ↑ capillaryhydrostatic pressure and ↑ capillary permeability– Continuous leak of plasma from intravascular space intointerstitial space– Associated imbalances of fluids, electrolytes and acid-baseoccur– Hemoconcentration– Lasts 24-36 hours
• Fluid remobilization– Capillary leak ceases and fluid shifts back into thecirculation– Restores fluid balance and renal perfusion• Increased urine formation and diuresis– Continued electrolyte imbalances• Hyponatremia• Hypokalemia– Hemodilution
SYSTEMIC CHANGES• Cardiac– Decreased cardiac output• Pulmonary– Respiratory insufficiency as a secondary process– Can progress to respiratory failure– Aggressive pulmonary toilet and oxygenation• Gastrointestinal– Decreased or absent motility (may need NG tube)– Curling’s ulcer formation
• Metabolic– Hypermetabolic state• Increased oxygen and calorie requirements• Increase in core body temperature• Immunologic– Loss of protective barrier– Increased risk of infection– Suppression of humoral and cell-mediated immuneresponses
ACUTE PHASE• Clinical shock• External loss of plasma• Loss of circulating red cells• Burn edema
SUB ACUTE PHASE• Diuresis• Clinical Anemia• Accelerated metabolic rate• Nitrogen Disequilibrium• Bone and joint changes• Endocrine Disturbances• Electrolyte and chemical imbalance• Circulatory Derangements• Loss of of function of skin as an organ
Body’s Response to Burns• Emergent Phase (Stage 1)– Pain response– Catecholamine release– Tachycardia, Tachypnea, Mild Hypertension, MildAnxiety• Fluid Shift Phase (Stage 2)– Length 18-24 hours– Begins after Emergent Phase• Reaches peak in 6-8 hours– Damaged cells initiate inflammatory response• Increased blood flow to cells• Shift of fluid from intravascular to extravascular space– MASSIVE EDEMA
• Hypermetabolic Phase (Stage 3)–Last for days to weeks–Large increase in the body’s need fornutrients as it repairs itself• Resolution Phase (Stage 4)–Scar formation–General rehabilitation and progression tonormal function
Jackson’s Theory of Thermal Wounds• Jackson’s Theory of Thermal Wounds– Zone of Coagulation• Area in a burn nearest the heat source that suffers the mostdamage as evidenced by clotted blood and thrombosedblood vessels– Zone of Stasis• Area surrounding zone of coagulation characterized bydecreased blood flow.– Zone of Hyperemia• Peripheral area around burn that has an increased bloodflow
Severity is determined by:–depth of burn–extend of burn calculated in percent of totalbody surface (TBSA)–location of burn–patient risk factors
CLASSIFICATION OF BURNS• First degree—injury localized to theepidermis• Superficial second degree—injury to theepidermis and superficial papillary dermis• Deep second degree—injury through theepidermis and deep upto reticular dermis• Third degree—full-thickness injury through theepidermis and dermis into subcutaneous fat• Fourth degree—injury through the skin andsubcutaneous fat into underlying muscle orbone
CLASSIFICATION OF BURNS
Superficial Burn : 1st Degree Burn• Reddened skin• Pain at burn site• Involves only epidermis• Blanch to touch• Have an in-tact epidermalbarrier• Do not result in scarring• Examples : Sun-burn, minorscald from a kitchen accident• Treatment is aimed atcomfort with topical soothingagents +/- NSAIDs
Partial-Thickness Burn: 2nd DegreeBurn• Intense pain• White to red skin• Blisters• Involves epidermis & papillarylayer of dermis• Spares hair follicles, sweatglands etc.• Erythematous & blanch to touch• Very painful/sensitive.• No or minimal scarring.• Spontaneously re-epithelializefrom retained epidermalstructures in 7-14 days
Deep second degree burn• Injury to deeper layers of dermis –reticular dermis• Appears pale & mottled• Do not blanch to touch• Capillary return sluggish or absent• Less painful, remain painful to pinprick• Takes 14 to 35 days to heal byre-epithelialisation from hairfollicles & sweat gland,keratinocytes often with severe scarring• Contractures possible• Require excision & skin grafting
Full-Thickness Burn:3rd Degree Burn• Dry, leathery skin(white, darkbrown, orcharred)• Loss of sensation(little pain)• All dermallayers/tissue maybe involved• Always requiresurgery.
Fourth degree burn• Involves structures beneath the skin- muscle,bone.
ASSESSMENT OF BURNS• Rule of Nine–Best used for large surface areas–Expedient tool to measure extent of burn• Rule of Palms–Best used for burns < 10% BSA
AREA OF PALM = 1% BODY SURFACE AREA
ManagementPre-hospital care• Ensure rescuer safety• Stop the burning process: Stop, drop and roll• Check for other injuries.A standard ABC (airway, breathing, circulation)check followed by a rapid secondary survey.
• Cool the burn wound:AnalgesiaSlows the delayed microvascular damage,Minimum of 10 minEffective up to 1 hour after the burn injury• Give oxygen• Elevate
Hospital care• A : Airway control.• B :Breathing and ventilation.• C :Circulation.• D: Disability – neurological status.• E :Exposure with environmental control.• F :Fluid resuscitation.
The criteria for acute admission to a burns unit• Suspected airway or inhalational injury• Any burn likely to require fluid resuscitation• Any burn likely to require surgery• Patients with burns of any significance to the hands, face,feet or perineum• Patients whose psychiatric or social background makes it• inadvisable to send them home• Any suspicion of non-accidental injury• Any burn in a patient at the extremes of age• Any burn with associated potentially serious sequelae• including high-tension electrical burns and concentrated• hydrofluoric acid burns
AirwayRecognition of the potentially burnedairway• A history of being trapped in the presence ofsmoke or hot Gases• Burns on the palate or nasal mucosa, or loss ofall the hairs• in the nose : Deep burns around the mouth andneck
Airway• Burned airway• Early elective intubation is safest• Delay can make intubation very difficultbecause of Swelling• Be ready to perform an emergencycricothyroidotomy if intubation is delayed
Breathing• Inhalational injury• Thermal burn injury to the lower airway• Metabolic poisoning:Carboxyhaemoglobin• Mechanical block to breathing:Escharotomy
Circulation• Maintain iv line with wide bore canulaperipherally• One central line• Escharotomy of limbs if circulatorycompromise in circumferential burns
Fluids for resuscitation• In children with burns over 10% TBSA andadults with burns over 15% TBSA, considerthe need for intravenous fluid resuscitation• If oral fluids are to be used, salt must be added• Fluids needed can be calculated from astandard formula• The key is to monitor urine output
• Parkland Formula:Total percentage body surface area × weight(kg) × 4 = volume (ml)• Half this volume is given in the first 8 hours,and• the second half is given in the subsequent 16hours.
• Crystalloid : Ringer lactate• Hypertonic saline• Human albumin solution• Colloid resuscitation
• The commonest colloid-based formula is theMuir and Barclay formula:0.5 × percentage body surface area burnt ×weight = one portion;• Periods of 4/4/4, 6/6 and 12 hoursrespectively;• one portion to be given in each period.
Assessment of adequacy of fluidreplacement• Urine output is most commonly used parameter• Urine osmolarity is the most accurate parameter• U/O > 0.5-1.0 ml/kg/hr• CVP 5-10 cm/H2O.• U/O > 2ml/kg/hr – sign of overhydration
TREATING THE BURN WOUNDEscharotomy• Circumferential full-thickness burns to thelimbs require emergency surgery.• The tourniquet effect of this injury is easilytreated by incising the whole length of full-thickness burns..
Escharotomy• Upper limb: Mid-axial, anterior to the elbowmedially to avoid the ulnar nerve• Hand : Midline in the digits. Release musclecompartments if tight.• Lower limb: Mid-axial, Posterior to the anklemedially to avoid the saphenous vein• Chest: Down the chest lateral to the nipples,across the chest below the clavicle and acrossthe chest at the level of the xiphisternum
Fasciotomy• Fascia = thick whitecovering of muscles.• Fasciotomy = fascia isincised (and often overlyingskin)• Skin and fascia split opendue to underlying swelling.• Blood flow to distal limb isimproved.• Muscle can be inspected forviability.
Debridement• Types of debridement:1. Auto debridement.2. Tangential excision (at the end of 1st week)3. Staged primary debridement (1-3 days postburn).This early debridement of dead tissue interruptsand attenuates the systemic inflammatoryresponse and normalize immune function.4. For deep circumferential burn, urgentescharotomy is done
BLISTERS• Intact blister- barrier to microbial invasion• Intact blister creates moist environment hencemore rapid reepithelialization• More rapid angiogenesis• Rupture of blisters under contaminatedconditions may increase infection rates
BLISTERS• In the pre-hospital setting, there is no hurry toremove blisters.• Leaving the blister intact initially is lesspainful and requires fewer dressing changes.• The blister will either break on its own,or the fluid will be resorbed.
• AnalgesiaAcute• Small superficial burns : simple oral analgesia,Topical cooling• Large burns: intravenous opiates.Subacute• Large burns: continuous analgesia is required,beginning with infusions and continuing with oraltablets such as slow-release morphine.
Nutrition• Burns patients need extra feeding• A nasogastric tube should be used in allpatients with burns over 15% of TBSA• Removing the burn and achieving healingstops the catabolic drive.
NutritionSutherland formula• Children: 60 kcal/ kg + 35 kcal%TBSA• Adults: 20 kcal /kg + 70 kcal%TBSAProtein20% of energy1.5 to 2 g/kg protein/day
Tetanus prophylaxis• Tetanus toxoid, 0.5 mL intramuscularly, if thelast booster dose was more than 5 years beforethe injury.• If immunization status is unknown,human tetanus immunoglobulin 250 to 500units, I.M. plus tetanus toxoid in opposite side
Monitoring and control of infection• Burns patients are immunocompromised• They are susceptible to infection from manyroutes• Sterile precautions must be rigorous• Swabs should be taken regularly• A rise in white blood cell count,thrombocytosis and increased catabolism arewarnings of infection
Topical treatment of deep burns• 1% silver sulphadiazine cream• 0.5% silver nitrate solution• Mafenide acetate cream• Serum nitrate, silver sulphadiazine and ceriumnitrate
Principles of dressings for burns• Full-thickness and deep dermal burns needantibacterial dressings to delay colonisationprior to surgery• Superficial burns will heal and need simpledressings• An optimal healing environment can make adifference to outcome in borderline depthburns
Surgical treatment of deep burns• Early debridement and grafting is the key to effectivelytreating• deep partial- and full-thickness burns in a majority ofcases• Deep dermal burns need tangential shaving and split-skin grafting• All but the smallest full-thickness burns need surgery• Should be ready for significant blood loss• Topical adrenaline reduces bleeding• All burnt tissue needs to be excised
Surgical treatment of deep burns• Proper dressing should be done• Postoperative management requires carefulevaluation of fluid balance and levels ofhaemoglobin.• Physiotherapy and splints are important inmaintaining range of movement and reducingjoint contracture
Delayed reconstruction of burns• Eyelids must be treated before exposurekeratitis arises• Transposition flaps and Z-plasties with orwithout tissue expansion are useful• Full-thickness grafts and free flaps may beneeded for large or difficult areas• Hypertrophy is treated with pressuregarments/Silicone patch(6-18 month)• Pharmacological treatment of itch is important
Chemical BurnsAcids• Protein injury by hydrolysis.• Thermal injury is made with skin contact.Alkali• Saponification of fat• Hygroscopic effect- dehydrates cells• Dissolves proteins by creation of alkalineproteinates (hydroxide ions)
Electrical Burns• Greatest heat occurs at the points of resistance– Entrance and Exit wounds– Dry skin = Greater resistance– Wet Skin = Less resistance• Longer the contact, the greater the potential ofinjury– Increased damage inside body• Smaller the point of contact, the moreconcentrated the energy, the greater the injury.
• Electrical Current Flow–Tissue of Less Resistance• Blood vessels• Nerve–Tissue of Greater Resistance• Muscle• Bone
Results in………..–Serious vascular and nervous injury–Immobilization of muscles–Flash burns– Late complications: cataracts, progressivedemyelinating neurologic loss
– Assess patient• Entrance & Exit wounds• Remove clothing, jewelry, and leather items• Treat any visible injuries– Thermal burns• ECG monitoring– Bradycardia, Tachycardia, VF or Asystole– Treat cardiac & respiratory arrest– Aggressive airway, ventilation, and circulatory management.• Consider Fluid bolus for serious burns– 20 ml/kg• Consider Sodium Bicarbonate: 1 mEq/kg• Consider Mannitol: 10 g
Radiation burns• Local burns causing ulceration need excisionand vascularised flap cover – usually with freeflaps• Systemic overdose needs supportive treatment
Cold injuries• The damage is more difficult to define andslower to develop than burns• Acute frostbite needs rapid rewarming, thenobservation• Delay surgery until demarcation is clear